<div class="grid_4">
     <div class="da-panel">
        <div class="da-panel-header">
            <span class="da-panel-title">
                    <img src="images/icons/color/accept.png" alt="" />
                                        <?=$title;?>
            </span>
        </div>
        
		<div class="da-panel-content">
            <form id="da-ex-validate1" class="da-form">
                <div id="da-ex-val1-error" class="da-message error" style="display:none;"></div>
                    <div class="da-form-inline">
                        
                        <div class="da-form-row">
                            <label><?=lang('name')?><span class="required">*</span></label>
                            <div class="da-form-item large">
                                <input type="text" name="req1" />
                            </div>
                        </div>
                        
                        <div class="da-form-row">
                            <label><?=lang('group')?><span class="required">*</span></label>
                            <div class="da-form-item large">
                                <select name="group" style="width:30%;">
                                    <option value="Administrator">Administrator</option>
                                    <option value="User">User</option>
                                </select>
                            </div>
                        </div>
                        
                        <div class="da-form-row">
                            <label><?=lang('gender')?><span class="required">*</span></label>
                            <div class="da-form-item large">
                                <select name="group" style="width:20%;">
                                    <option value="<?=lang('male')?>"><?=lang('male')?></option>
                                    <option value="<?=lang('female')?>"><?=lang('female')?></option>
                                </select>
                            </div>
                        </div>
                        
                        <div class="da-form-row">
                            <label>Email<span class="required">*</span></label>
                            <div class="da-form-item large">
                                                    <input type="text" name="email1" />
                            </div>
                        </div>
                                            <div class="da-form-row">
                                                <label>URL<span class="required">*</span></label>
                                                <div class="da-form-item large">
                                                    <input type="text" name="url1" />
                                                </div>
                                            </div>
                                            <div class="da-form-row">
                                                <label>Password <span class="required">*</span></label>
                                                <div class="da-form-item large">
                                                    <input id="pass1" type="text" name="pass1" />
                                                </div>
                                            </div>
                                            <div class="da-form-row">
                                                <label>Confirm Password <span class="required">*</span></label>
                                                <div class="da-form-item large">
                                                    <input type="text" name="cpass1" />
                                                </div>
                                            </div>
                                            <div class="da-form-row">
                                                <label>Round Number<span class="required">*</span></label>
                                                <div class="da-form-item large">
                                                    <input type="text" name="digits1" />
                                                </div>
                                            </div>
                                        </div>
                                        <div class="da-button-row">
                                        	<input type="submit" value="Validate Me" class="da-button red" />
                                        </div>
                                    </form>
                                </div>
                            </div>
                        </div>